Injured Workers' Alliance Contribution

You receive an Oregon state income tax credit of $50 (single filers) or $100 (joint filers) when taxes are owed.
Information is available from the state at http://www.oregon.gov/DOR/PERTAX/docs/101-662.pdf.

 

Your Name:

Street Address:

City:

State & Zip:

Contribution Amount:

_________________________________________

____________________________________________________

_________________________________________

___________________________

_________


Election law requires that a committee gather the following. It is only listed on reports if contributions total over $100 during an election cycle.

Employer Name:

Employer Address:

Your Occupation:

_______________________________________________ 

_________________________________________________________   AND

______________________________________________

Reminder: Make sure you mark your calendar so you use the tax credit on next year's tax return


Please make your check payable to Injured Workers' Alliance PAC.

Mail it along with a printed copy of this form to:
Injured Workers' Alliance
PO Box 614
West Linn, OR 97068

Web site: http://www.injuredworker.org

Thank you very much for assisting our efforts!